Art of Abdominal Contouring: Advanced Liposuction Sanjay Parashar
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HistoryCHAPTER 1

“The sooner you make your first five thousand mistakes the sooner you will be able to correct them”
—Kimon Nicolaides
Kimon Nicolaïdes was a Greek–American artist of 18th century. During World War I, he served in the US Army in France as a camouflage artist. He advocated a three-pronged way of learning to draw: through (1) slow and meticulous contour drawing, (2) free and rapid gesture drawing, and (3) vigorous tonal drawings of weight or mass. The same creative intellectual endeavor is required to mold the bodily morphology of the patients.
But be wiser and learn from others’ mistakes! Do whatever it takes to prevent mistakes and that is why history is important.
In 1921, Charles Dujarrier, a French surgeon, curetted a ballerina's knees to create a better shape, but the patient developed gangrene and required an amputation.1 Think! What would have gone wrong? Anything from improper cannula, technique, direct vascular injury, postoperative compression, lack of follow-up. What do we learn from this?
In 1964, Joseph Schrudde developed curettage and suction.2 In 1976, Georgio and Fischer, Italian surgeons, developed a fat-removing system with a hollow cannula and an internally rotating planatome and cellusuctiontome.1,3 They also introduced the concept of cross-tunneling for more uniform results. The concept of cross-tunneling is still applicable and a uniform contour cannot be achieved by two incisions that allows cannula movement in same direction.
Other cannulas were developed by Kesselring and Meyer (1978) and Illouz (1977); the latter also developed the wet technique. Dr Ives Gerard Illouz took a major step ahead in the field of liposuction by introducing negative pressure device with high suction power connected to a cannula. He also developed the wet technique in which he used hypotonic saline solution and hyaluronidase in order to perform dissecting hydrotomy for bloodless fat removal.1,2,4
Pierre Fournier (1983)5-7 favored the syringe technique and instructed physicians to use the cross-tunneling technique. He relied on the dry method without subcutaneous infiltration.
The dry technique uses general anesthesia without any preoperative infiltration of vasoconstrictive solution. The wet technique achieves a moderate reduction in blood loss by using a small amount of epinephrine.
In 1984, Hetter introduced epinephrine into solutions. The superwet infiltration technique, the use of 1.5 mL of solution for each 1 mL of aspirated fat, has been utilized since 1986, popularized by Fodor.8
In 1987, Jeffery Klein discussed the tumescent technique that used massive infiltration of the subcutaneous tissue.9 The proportion of infiltrated liquids to aspirated liquids has developed as follows: dry liposuction, 0:1; wet, 1:1; superwet,1.5:1; tumescent >2:1.
With these modifications, liposuction has become a safe and effective procedure. Nevertheless, with traditional liposuction, the treatment of fibrous area (as in dorsum, gynecomastia, and secondary liposuction cases) may become difficult.
In the late 1980s, Zocchi introduced the use of ultrasonic device to release continuous energy to break the fat cells. Scuderi popularized the use of first-generation ultrasonic device which delivered ultrasound energy through blunt solid cannula. This was the beginning of ultrasonic assisted liposuction (UAL).10,112
The second-generation UAL introduced a hollow cannula for simultaneous liposuction with an internal diameter of only 2 mm.12 This was not very efficient.
The ultrasound assisted liposuction had increased the risks of burns and related complications. Hence ultrasonic device became unpopular due to the increased risk of burns and skin damage. There was a need to improvise on the technology. The third generation UAL device was developed that later became popular as VASER (vibration amplification of sound energy at resonance). It uses small-diameter titanium probes (2.9 mm and 3.7 mm) with grooves near the tip to increase fragmentation efficiency by redistributing energy. So there was less energy at the tip reducing the risk of burns. The machine also uses pulsed energy as compared to continuous energy.
Performance of superficial lipoplasty with standard lipoplasty cannulas, as reported by Souza pinto,13 Gasperoni, and Gasparotti,14,15 expanded the boundaries of body contouring by enabling the removal of fat from the superficial layers. However, there is a significant risk of dermal damage, scarring, waviness, and contour irregularities, as well as cutis marmorata when excessive fat removal was performed. It is a long learning curve to understand the technique of superficial liposuction without causing dermal damage. Some suggested to leave 1 cm of fat under the dermis.15,16
Scheflan and Tazi17 reported the superficial application of ultrasound energy to produce “skin stimulation” for purposes of retraction was associated with burns, scarring, waviness, and contour irregularities. Jewell et al.18 first reported on the clinical application of a third-generation ultrasound lipoplasty device that utilized pulsed low-power ultrasound and high-efficiency, small-diameter solid titanium probes.
Mentz and Ersek19,20 pointed out that traditional lipoplasty techniques often fail to achieve the aesthetic goal of a “washboard” abdominal contour because “subdermal fat obscures the muscular detail.” The Mentz technique called “abdominal etching” used differential lipoplasty to detail abdominal musculature, specifically the rectus abdominis muscle, between the linea alba and the linea semilunaris, while also addressing the tendinous inscriptions (intersectiones tendineae) of the rectus abdominus muscle. However, abdominal etching was designed specifically for male body builders with between 8% and 15% body fat, and was limited to only the anterior abdominal wall.
In 2003, Hoyos21 presented a new technique at a Colombian National Congress, that he termed “high-definition liposculpture” (HDL). The term “liposculpture” defined the technique as not simply fat removal but as an artistic approach designed to emulate surface anatomy. As Gasparotti mentioned, “I recognized that working superficially I had the ability to go well beyond the simple removal of fatty bulges… Why not use it as a sculpting tool to obtain the imaginary shape, the ideal profile we dream about creating?”22
HDL was developed through the study of art and anatomy of the human musculature, as an artistic treatment of the human form to create not only a slim figure, but also the appearance of a highly developed musculature.
High-definition liposculpture elevates the Mentz concept of abdominal etching to a three-dimensional approach. In this approach, one needs to consider the muscular anatomy of the region and hence it can be applied to any body parts including torso, legs, arms, and back. The differing aesthetic goals of male and female body contouring are integrated into this method, as are key areas such as the pectorals in male and the gluteal area in female.
However, it requires a lot of training, experience, and understanding to achieve exceptional results by HDL. Yet another challenge is the long and exhausting surgical hours, postoperative discomfort and healing period, and long term and close follow-up to avoid undesirable results.
Vibration amplification of sound energy at resonance is very useful and complementary to achieve HDL because it emulsifies the fat uniformly just like an artists’ “clay.” That will make it easy to sculpt and enhance muscular anatomy and minimize discomfort and healing time. This started the era of VASER-assisted high-definition liposculpture that uses combination of VASER and HDL.
VASER-assisted high-definition liposculpture embodies the ultimate understanding of how superficial anatomy influences external appearance. Developed through the study of “surface anatomy” of human musculature much as an artist would view the human form,23,24 VASER-assisted high-definition liposculpture begins where superficial lipoplasty ends. It highlights the importance of contributions made to the aesthetics of the human form by both the superficial and deep fat layers when these layers are properly proportioned both between and over the muscle groups.3
The technique has evolved tremendously over decades but the major improvement was to minimize complications, improve scars, and improve shape of umbilicus. But there were more challenges: patients wanted better results, better aesthetic outcome, and certainly longer-lasting results.
In the year 1995, Matarasso25 published extensive work on the aesthetics of abdomen and described methods to improve the results. Such as upper abdomen was not considered in abdominoplasty and hence it would bulge out postoperatively and in long-term. So, Matarraso recommended simultaneous liposuction along with abdominoplasty to improve the contour for long-term.
He suggested that omitting the rejuvenation of one of the abdominal aesthetic units can result in disproportion, disharmony, and patient discord. To avoid this problem, related abdominal aesthetic units should be addressed in both open and closed abdominal contour procedures.
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